Previous Articles - The first angry feelings - A 4-month-old first baby who 'Just doesn't sleep' - When a child is misdiagnosed

Q. Chronic insomnia is part of autistic spectrum disorders. There are no treatments and no cures. The only way to "manage" it is the usual advice on preparing for sleep. However, in a spectrum child, the usual measures will not work well -- they only make it a little bit less of a problem. In the case of spectrum disorders, the chronic insomnia will be a life-long problem.

Chronic insomnia in adulthood is thought to cause obesity, high blood pressure and high cholesterol, all of which I have. These parents have a wonderful opportunity to look into this possibility at a very early age. If this is the child's problem, they need to prepare themselves for the fact that their child will have this problem his entire life, and learn coping strategies.

A. Thank you for your comments. We'd like to add a few clarifying ones: Sleep disturbances may occur in children and adults with autism spectrum disorders. However, this is not a hallmark of these disorders, and many "on the spectrum" do not have insomnia. When they do, it will not necessarily become chronic.

There may be special challenges to treating problems like insomnia in children with autism spectrum disorders. But these children are not all neatly categorized, and are quite different from each other in many respects.

Also, insomnia is not directly linked to the condition. So we can't agree with your generalization that strategies to improve sleep are unlikely to help. It would also be both discouraging and inaccurate to assert that insomnia in a child with autism will be life-long.

We don't have a crystal ball, and that may be just fine. Greater humility about our ability to predict allows family to hold onto hope. And hope is a critical ingredient for the healing that can occur.

There are treatments for autism spectrum disorder, including, for example, a program called "Floortime" which is part of a "Developmental, Individualized, and Relational" approach. (For more information, see the Web site from the nonprofit Interdisciplinary Council on Developmental and Learning Disorders, www.icdl.com.)

The prognosis for autism spectrum disorders is far more variable than once thought and many children can make great strides in mastering the challenges of these disorders when they get the help they need and deserve.

Perhaps our greatest concern is your suggestion that this 4-month-old's sleep troubles should trigger an early diagnosis of autism. We agree that the extent of this baby's sleeplessness, as described, was alarming. We urged the parents to seek further medical consultation.

But taken alone, a sleep disturbance isn't specific enough to make a diagnosis of autism, and to do so for a 4-month-old without very solid evidence might actually be damaging to the infant, the parents and their relationship.

We believe that autism spectrum disorders may often be detectable earlier than they are, and that earlier intervention would improve a child's chances for the best possible future.

But medicine does not yet possess the tools to do this with certainty at such a young age.

Instead, when we note symptoms that are suggestive of autism in young infants, but that aren't sufficient to confirm the diagnosis, and may just as well indicate an entirely different problem, we do not use this label, but instead simply help parents to understand the symptoms themselves, and to start working on them.

These early symptoms include failure to make eye contact, arching and stiffening when cuddled, lack of responsiveness to a parent's smiles and cooing.

None of these confirms a diagnosis of autism but would prompt us to recommend early intervention to help infants learn to engage in social relationships, an ability that usually emerges in the first months of life.

It can be difficult for parents to face that their young infant has a special need to be addressed right now, but it may be even harder if they are overwhelmed by the prospects of "the rest of their lives."

Often it is more effective to mobilize people to take on what they can face in the present, and to talk about the future only when they are ready, and only to the extent that we have solid information to offer.

While we can refer to risks and probabilities for groups of people with a particular diagnosis, we really don't know enough to be able to predict the future for any individual infant who manifests any of these symptoms, or for that matter, a sleep disturbance.

Unfortunately, premature diagnosis is sometimes required in order to obtain insurance coverage for early intervention. But this kind of diagnostic labeling can interfere with a child's development and with parents' attachment to the child, particularly in a society that is intolerant of differences and disabilities. Not all are.

Although we disagree with some of your suggestions, we appreciate your generous concern for this family.

Dr. Brazelton heads the Brazelton Touchpoints Project, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is director of Special Initiatives at the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

c.2008 T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.